Workers’ Compensation Forms

Workers’ Compensation provides eligible workers who are either injured or who become ill during the course of employment with medical coverage and, if applicable, disability coverage. The program is legislated by State law. The City’s self-funded Workers’ Compensation program is administered by LWP Claim Solutions, Inc. (LWP).

As of March 2023, the workers' compensation forms have been enhanced in order to streamline the claim submission process.

If you are injured or become ill during the course of your employment: 

Download the updated Workers' Compensation Claims Full Packet 03 2023 Updated Fillable.  File claim within 24 hours. 

• A new form should be downloaded for each new claim, do not reuse old forms.
• This packet contains for DWC-1, Form 5020, and questions from the claims administrator. Claimant (employee), their supervisor, and department designee for workers' comp claims should fill their sections to the best of their ability.
• Non-fillable version to download Workers' Compensation Claims Full Packet 03 2023 - Printable

Steps to fill out packet

1. Claimant to answer questions on page one, fill out DWC-1 Employee Section, and sign.  Then electronically route to their supervisor.
2. Supervisor to fill out Employer section of DWC-1, all of Form 5020, and sign. Then electronically route to department designee for workers' comp claims. If you are unsure of who this is, contact human.resoruces@cityofsanrafael.org or 415-485-3474.
3. Department Designee for workers' comp claims answer questions on the form to the best of your knowledge. Review and ensure both the DWC-1 and Form 5020 are filled and signed. Sign your name and email. Then email the packet to froi@lwpclaim.com and CC human.resources@cityofsanrafael.org. 

For questions about any forms, contact human.resources@cityofsanrafael.org or call 415-485-3474. 

Additional information or employees

• LWP- Memo to All Employees
  • Workers' Compensation Policy
  • Industrial Injury Medical Panel - flyer with the City's required locations for an employee to seek medical treatment (if no predesignation is on file)
  • Predesignation of Personal Physician - if you prefer to have predesigned personal physician on file
  • Statement to Treating Physician
• Safety Report Instructions & Safety Report Forms
  • Safety Report 
  • Safety Report Instructions 
  • Safety Action Report
  • Safety Action Report Instructions 
• Workers' Comp FAQ’s
• Workers' Comp Fact Sheet
  • Cal Osha Reporting Requirements
• RU-91 forms (Job Analysis)
  • Job Descriptions

If needed, LWP can be reached at

LWP Claims Solution, Inc.
PO Box 349016 Sacramento, CA 95834-9016
T: (800) 565-5694
Fax: (408) 725-0395
Email: Info@lwpclaims.com